untitled

Journal of Athletic Training 2014;49(1):128–137

doi: 10.4085/1062-6050-49.1.06

Ó by the National Athletic Trainers’ Association, Inc

www.natajournals.org

consensus statement

Inter-Association Consensus Statement on Best

Practices for Sports Medicine Management for

Secondary Schools and Colleges

Ron Courson, ATC, PT, NREMT-I, CSCS (Co-Chair)*; Michael Goldenberg, MS,

ATC (Co-Chair)*†; Kevin G. Adams, CAA‡; Scott A. Anderson, ATC§;

Bob Colgate||; Larry Cooper, MS, LAT, ATC*; Lori Dewald, EdD, ATC, MCHES,

F-AAHE¶; R.T. Floyd, EdD, ATC*; Douglas B. Gregory, MD, FAAP#; Peter A.

Indelicato, MD**; David Klossner, PhD, ATC††; Rick O’Leary, MS, ATC, AT/L*;

Tracy Ray, MD ‡‡ ; Tim Selgo, MEd §§; Charlie Thompson, MS, ATC*;

Gary Turbak, DHSc, ATC||||

*National Athletic Trainers’ Ass ociation; †The Lawrenc eville School; ‡National Interscholastic Athletic Administrators

Association; §College Athletic Trainers’ Society; ||National Federation of State High School Associations; ¶American

College Health Association; #American Academy of Pediatrics; **American Orthopaedic Society for Spor ts Medicine;

††National Collegiate Athletic Association; ‡‡American Medical Society for Sports Medicine; §§Nat ional Association of

Collegiate Directors of Athletics; ||||National Association of Intercollegiate Athletics

lthough signiﬁcant advances have occurred within

athletic training and sports medicine in the last few

decades, the ﬁelds can be traced back to the

ancient Greek civilization and the establishment of the

Olympic Games.

Today, more than 900 different sports are

practiced worldwide; however, not all of them have a

physical component.

In the United States alone, more than

7.6 million students participate in organized secondary

school athletics, whereas in 2012, more than 420 000

student–athletes represented their colleges in athletic

play.

3,4

Athletics are part of the educational process for

many students and add to the growth of the adolescent and

young adult. Secondary school students involved in

athletics with proper coaching demonstrate better academic

achievement, miss less school, and learn lifelong lessons

for success.

It is estimated that more than 1.4 million injuries occur

yearly to athletes playing 9 sports at the secondary school

level and approximately 209 000 yearly at the collegiate

level across 25 National Collegiate Athletic Association

sports (Datalys Center for Sports Injury Research and

Prevention, written communication, April 15, 2013).

These statistics take into account injuries that occur in

both practice and game situations. In addition, an unknown

number of injuries occur in nonscholastic sports, primarily

as a result of overuse, either alone or resulting from the

cumulative effects of nonscholastic and scholastic sports

participation. As concerns grow over the number of

musculoskeletal injuries, as well as life-threatening condi-

tions and traumatic brain injuries such as concussions, more

secondary schools and colleges are being forced to

reevaluate the medical services they provide their athletes.

Athletes at secondary schools with proper medical teams

that include an athletic trainer sustain a lower incidence of

injuries (both acute and recurring) than athletes at schools

without athletic trainers. Athletes at secondary schools with

athletic trainers incur more diagnosed concussions, dem-

onstrating better identiﬁcation of these injuries.

According

to the American Medical Association,

‘‘ [T]he athletic

medicine unit should be composed of an allopathic or

osteopathic physician director with unlimited license to

practice medicine, an athletic health coordinator (preferably

an athletic trainer certiﬁed by the Board of Certiﬁcation, Inc

[BOC]), and other necessary personnel.’’ This document on

best practice in sports medicine management brings

together resources and views from 11 associations that

promote the health and well-being of the student–athlete.

Modern athletic training is a young, fast-growing health

care profession

; thus, many physicians and administrators

are still developing proper working relationships with and

appropriate expectations for athletic trainers. Wide varia-

tions exist in the administration of s ports medicine

programs, chains of command, and selection and evaluation

of the sports medicine team. Further, different athletic

training settings (eg, secondary schools, small colleges,

large colleges) vary widely in stafﬁng, resources, and

budgets.

This consensus paper is written to assist superintendents

of schools, secondary school athletic directors, college and

university athletic department administrators, athletic

trainers, and team and school physicians by presenting

the best practices in sports medicine management in the

secondary and collegiate settings. This document outlines

important considerations regarding (1) duties and respon-

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sibilities of the athletic trainer and team physician; (2)

supervisory relationships and the chain of command within

the sports medicine team; (3) decision-making authority

regarding approval for participation of student–athletes, as

well as injury management and return to sport participation

status after injury or illness; (4) administrative authority for

the selection, renewal, and dismissal of related medical

personnel; and (5) performance-appraisal tools for the

sports medicine team. To date, these recommendations

have been endorsed by the American Academy of

Pediatrics, American College Health Association, Ameri-

can Medical Society for Sports Medicine, American

Orthopaedic Society for Sports Medicine, College Athletic

Trainers’ Society , National Association of Collegiate

Directors of Athletics, National Association of Intercolle-

giate Athletics, National Athletic Trainers’ Association

(NATA), National Federation of State High School

Associations, and National Interscholastic Athletic Admin-

istrators Association.

Athlete-Centered Medicine

The term ‘‘ patient-centered care’’ refers to the delivery of

health care services that are focused on the individual

patient’s needs and concerns. The same concept, ‘‘athlete-

centered care,’’ applies in sports medicine.

Sports

medicine physicians and athletic trainers are often present-

ed with an ethical dilemma when an individual athlete’s

best medical interests conﬂict with the performance

expectations of authority ﬁgures (eg, coaches, parents). In

almost every circumstance involving the provision of

medical care, the legal responsibility for the decision to

allow an injured athlete to return to sports participation

ultimately belongs to a licensed physician.

In many

situations, a physician who is a sports medicine specialist

will authorize an athletic trainer to guide the rate at which

an injured athlete is exposed to progressively increasing

physical demands, but the physician is still ultimately

responsible for the athletic trainer’s clinical practice

decisions.

The Appendix provides 10 principles to guide institutions

and organizations in assessing existing administrative

policies, procedures, and professional service relationships.

Many of these principles correspond to concepts addressed by

the BOC Standards of Professional Practice,

the Code of

Ethics of the NATA,

and state medical practice regulations.

Duties and Responsibilities of the Athletic Trainer and

Team Physician

All stakeholders who have as their primary focus the

immediate and long-term health and well-being of the

individ ual athlete should be involved in creating the

speciﬁc institution’s job descriptions and expectations for

all sports medicine providers. This section outlines duties

and responsibilities of the athletic trainer, as well as the

team physician, who has ultimate responsibility for the care

provided by the sports medicine team.

The athletic trainer’s principal responsibility is to provide

for the well-being of individual athletes, allowing them to

achieve their maximum potential. To accomplish this,

athletic trainers work under the direction of the team

physician or school medical director and generally are

responsible for or actively involved with



Developing and implementing a comprehensive emergency

action plan;



Preventing, recognizing, diagnosing, referring, treating, and

rehabilitating injuries;



Establishing criteria for safe return to practice and play and

implementing the return-to-play process;



Establishing and operating treatment facilities for both

practice and game situations that follow national and local

standards;



Determining which venues and activity settings require the

on-site presence of the athletic trainer and team physician

and which require that they be available;



Establishing guidelines for the selection, ﬁt, function, and

maintenance of all athletic equipment;



Maintaining accurate medical records for each athlete;



Reviewing the design and impleme ntation of strength and

conditioning programs for safety and appropriateness

related to injury and illness prevention and providing

recommendations for change when indicated;



Establishing a safe practice and playing environment by

monitoring environmental risk factors such as meteorologic

conditions;



Communicating with coaches about each injured or ill

athlete’s condition and progress, in cooperation with the

team physician (Health Insurance Portability and Account-

ability Act [HIPAA] and Family Educational Rights and

Privacy Act [FERPA] rules apply); and



Communicating with parents or guardians and spouses

when appropriate about the injured or ill athlete’s status, in

cooperation with the team physician (HIPAA/FERPA rules

apply).

Like all health care providers, the team physician’s ﬁrst

obligation is to the well-being of the athletes under the care

of the sports medicine team. The physician’s judgment

should be governed only by medical considerations. The

team physician should actively integrate his or her medical

expertise with that of other health care providers, including

medical specialists, athletic trainers, and allied health

professionals.

The team physician must have the ultimate

authority for making medical decisi ons regarding the

athlete’s safe participation.

The team physician has ultimate responsibility for the

following duties



Ensuring prope r preparation for safe return to participation

after an illness or injury;



Developing a chain of command, with the team physician at

the top;



Coordinating preparticipation screenings, examinations, and

evaluations;



Managing on-the-ﬁeld injuries;



Providing medical management of injury and illness;



Coordinating rehabilitation and return to participation;



Integrating his or her medical expertise with that of other

health care providers, including medical specialists, athletic

trainers, and allied health professionals;



Providing appropriate education and counseling regarding

nutrition, strength and conditioning, ergogenic aids, sub-

stance abuse, and other medical issues that could affect the

athlete;



Ensuring proper documentation and medical record keep-

ing;

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

Establishing and deﬁning the relations hips among all

involved parties;



Educating athletes, parents or guardians, spouses, adminis-

trators, coaches, and other necessary parties of concern

regarding the athletes;



Planning and training for emerge ncies during competition

and practice;



Addressing equipment and supply concerns;



Providing appropriate event coverage; and



Assessing environmental conce rns and playing conditions.

Supervisory Relationships and Chain of Command

Within the Sports Medicine Team

A variety of models exist for sports medicine adminis-

tration. Regardless of the model used, responsibilities

should be clearly delineated, particularly in cases where

the athletic trainer may have responsibilities other than

medical care (eg, administr ative and academic). This

delineation should also deﬁne the supervisory relationships

for each area of responsibility so that potential role conﬂicts

are minimized and medical care is not sacriﬁced. Personnel

charged with supervising the athletic trainer’s various roles

must recognize the roles and responsibilities they share

with the athletic trainer. Deliberate attention must be given

to avoid providing conﬂicting directions to the athletic

trainer. All involved should realize that quality medical

care must supersede other responsibilities in times of

conﬂict. Clear delineation of responsibilities and supervi-

sory roles should be documented in advance of employment

and shared routinely as part of the hiring and selection

process, with subsequent documentation becoming part of

the employment contract. Typical models of supervisory

relationships in sports medicine and the advantages and

disadvantages of each are outlined in Table 1. Some

institutions may use models that vary from or are a

combination of those listed. Regardless of the model used,

to avoid both perceived and actual conﬂicts of interest, in

no case should there be a supervisory relationship in which

members of the sports medicine team report to a coach. The

athletic trainer should always report to the team or school

physician.

The potential for conﬂict of interest is omnipresent in

sports medicine. When sports medicine team members

provide care to athletes but are employees or appointees of

the institution, the potential exists for medical decisions to

be made that do not reﬂect the athlete’s best interest.

Regardless of the level of play, there is immense pressure

toward medical clearance so that athletes can participate.

However, to protect the athlete’s welfare, the institution

must establish a clear line of unchallengeable authority for

the team physician and athletic trainer.

16–18

This line of authority affords sports medicine providers

freedom from personal and professional bias in their ethical

and medicolegal obligations to the athlete’s health.

19,20

The

ability to act unencumbered fosters best-interest medical

decisions for and by athletes.

Institutional ownership of athletes’ health and welfare

can be demonstrated by including the athletic trainer or

team physician in the senior-level athletic administration.

This may be accomplished irrespective of the individual’s

appointment, whether through athletics, academics, univer-

sity health services, or private practice. Freedom in their

professional practice is ensured when neither the team

physician nor the athletic trainer has a coach as his or her

primary supervisor, and no coach has authority over the

appointment or employment of sports medicine provid-

ers.

12,16

Shared responsibility for sports safety involves not just

the sports medicine providers but the athletic administra-

tion, coaches, participants, and all associated with the

athletic program.

Medical decisions made in the athletes’

best interests ultimately serve the team’s best interests and

thereby provide for the institution’s well-being. The health

care provider’s primary responsibility is for the health and

safety of the student–athlete; however, an additional

responsibility is to protect the institution from liability.

Shared responsibility means that roles and authorities must

be distinct and well deﬁned, so that each party performs

duties unique to its discipline.

The team physician as the ﬁnal authority for medical

clearance is well established in the literature and as a

medicolegal principle.

15,18,21

Even when return-to-pl ay

decisions are delegated to an athletic trainer by a team

physician, the team physician is still ultimately responsi-

ble.

13,16

The institution must afﬁrm, in policy and protocol,

that sports medicine providers are empowered to make

best-interest decisions regarding the athlete at all times and

in all settings, and these decisions are authoritative and not

to be ignored.

This organizational principle must be

clearly communicated throughout, from the top down, both

in policy and in practice.

Communication is essential among the athlete, team

physician, athletic trainer, coaches, strength coaches,

parents or guardians, spouse, and administration regarding

the approval for participation and injury and illness

management. Sports medicine providers bound by HIPAA

and FERPA must adhere to mandated guidelines. All

communications must be legally compliant, accurate, and

consistent. Communication policies should outline speciﬁc

information that will be reported, by whom, to whom, and

in what manner.

Athletes bear responsibility to report injury and illness,

whether related or unrelated to sport. The athletic trainer

informs the team physician, with serial communications as

warranted. The athletic trainer communicates the athlete’s

participation status, including indicated activity limits, to

all coaches. Coaches should notify the athletic trainer when

they suspect an athlete has suffered an injury, illness, or

other adverse condition or is having a performance or

conditioning problem.

Return-to-play decisions should be made in an objective

and unbiased fashion and not inﬂuenced by the emotion of

competition.

Participation decisions should be based on

the best avail able evidence balan ced with the sp orts

medicine provider’s experience and judgment and with

specialty medical expertise as warranted.

Using objective criteria, the sports medicine provider

determines whether the athlete is allowed to participate

based on medical history, clinical evaluation, and symp-

toms. Progressive return to play with conditioning followed

by sport-speciﬁc activity, limited practice, and full practice

before resuming competition provides an individualized

approach th at allows each athlete to advance at the

appropriate rate given his or her condition and injury

severity.

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The athlete must be an active participant in medical

decisions. Parents or guardians and spouse may be involved

whether the athlete is a minor or emancipated.

All sports

medicine providers must clearly communicate the short-

term and long-term risks associated with continued athletic

participation.

Discussion points should include (1)

operative and nonoperative treatment options, with out-

comes as known, (2) treatment options that may delay

return to play but further the at hlete’s best medical

interests, and (3) treatment options that may hasten return

to play but are not in the athlete’s best medical interests.

The information must be in plain and simple language so

the athlete can understand any potential adverse conse-

quences, including catastrophic consequences, and make a

responsible decision.

Sports medicine providers should

assess the athlete’s understanding of the provided informa-

tion and capacity to make the necessary decision and ensure

that the athlete has the freedom to choose among the

medical alternatives without coercion or manipulation.

Economics must be considered in determining medical

clearance for participation. Team physicians and athletic

trainers must recognize the value of competitive athletics to

the athlete. Value may be measured in money. At all levels,

the athlete, his or her family, and interested others may

weigh dreams and ﬁnances along with the short-term and

long-term prognosis differently than the sports medicine

provider, even to the point of rejecting the athlete’s best

medical option.

Decision-Making Authority Regarding Participation of

Athletes, Injury Management, and Return-to-Sport

Participation After Injury or Illness in the Secondary

School Setting

Athletic trainers in the secondary school setting work in

conjunction with team physicians. The team physician

should be actively involved in the athletic health care

program across all teams throughout the year. Athletic

trainers need to develop a close working relationship with

their team physicians so that competent decision making

occurs through a collaborative process. Additionally, the

relationship must be one of mutual trust and conﬁdence.

This relationship facilitates open communication and

shared understanding of expectations of both parties. It

allows the athletic trainer to truly be an extension of the

team physician, operating under standing orders and

following written policies and procedures, to provide the

best possible care for the athletes. The team physician

should be willing to communicate with the athletic trainer

at any time and make athlete evaluation and follow-up care

a priority.

Students wishing to participate in sports must undergo a

comprehensive physical examination.

25–29

The purpose of

this screening is to search for condition s that might

predispose an athlete participating in sports to sudden

death, catastrophic injury, or signiﬁcant exacerbation of a

preexisting injury or illness without appropriate manage-

ment or rehabilitation.

Athletic trainers or other school

personnel should hold from participation any athlete who

has not provided the school with documentation verifying

successful completion of the examination.

All athletic trainers should have in place written policies

and procedures regarding injury management and return-to-

play decision-making criteria. These documents may be

developed jointly by the athletic trainer and team physician;

the ﬁnal written document should be approved by the team

physician and supported by the school administration.

Additionally, all schools should have written emergency

action plans that are practiced and followed in the event of

serious injury or illness.

27,28

The policies and procedures

should include speciﬁc return-to-play protocols for concus-

sions and other injury and illness situations. They should

also indicate that the team physician and, by extension, the

collaborating athletic trainer have the ﬁnal and unquestion-

able authority regarding return-to-play decisions. Although

parents and guardians, coaches, and family physicians can

prevent an ath lete from participating, none of these

individuals can overrule the decision of the team physician

working with the athletic trainer to withhold the athlete.

The athletic trainer’s administrative supervisor may be the

athletic director, but medical supervision should rest with

the team physician. Because the athletic trainer represents

the interests of the school, he or she should be supported in

medical decisions by the athletic director and other school

administrators, provided the athletic trainer follows estab-

lished policies and procedures.

Athletes should be encouraged to report their injuries

rather than hide them. If the athletic trainer believes that an

injury or illness warrants removal of the athlete from part or

all of the practice or competition, the athletic trainer should

have the authority to do so. Communication with the coach,

the athlete’s parents or guardians, and, in some cases, the

athletic director, is advised. However, communicating the

injury situation with those individuals should not be

misconstrued as seeking their approval to hold the athlete

out of competition or practice. Parents or guardians and

coaches are not allowed to override the athletic trainer’s

decision to remove or hold an athlete from participation due

to injury or illness.

When athletes seek medical attention outside the school’s

designated sports medicine providers, it is advisable for the

outside provider to contact the athletic trainer. Formal

methods of communication (forms) should be developed to

facilitate this exchange and describe the expectations of the

outside medical provider. Doing so creates a dialogue

between the outside p rovider and the school sports

medicine providers and facilitates agreement regarding

the rehabilitation process and return-to-play decisions.

When the outside provider deems the athlete medically

able to return to participation, it is the responsibility of the

athletic trainer to further determine functional (or sport-

speciﬁc) readiness to return to full participation. Athletic

trainers should work cooperatively with the treating

physicians and communicate frequently throughout the

athlete’s recovery.

Athletic trainers should recognize that physicians are the

higher medical authority.

The athletic trainer has an

ethical obligation to maximize the well-being of the athlete

and minimize the liabili ty exposure of the school.

Therefore, when the athletic trainer is unable to document

evidence of functional level s sufﬁcient to ensure the

athlete’s safety, the athletic trainer should express these

concerns to both the treating and team physicians. Whether

or not the treating physician agrees, authority for the ﬁnal

decision on the athlete’s return to play should remain with

the team physician. The team physician should be willing to

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Table 1. Typical Models of Supervisory Relationships in Sports Medicine

Model Advantages Disadvantages

Athletic trainer employed by athletic

department

Allows closer relationship between

sports medicine and athletic

department personnel

Potential conflict of interest if athletic personnel

have significant control over athlete’s

medical care

Most common model historically May enhance communication between

medical staff and athletics

Athletic trainer, team physician may be

challenged by athletic personnel over

inappropriate return to play, medical

clearance, other medical decisions

Team physician employed externally; serves

voluntarily or is contracted for service to

institution or school (athletics only or

institution as a whole), either through

retainer or fee for service

Potential for role conflict if AT must sacrifice

athlete medical care responsibilities for

athletic department administrative,

educational responsibilities

Athletic trainer typically splits responsibilities

between athletics and academics per

contract or employment agreement; or AT

may be employed by athletics and

compensated additionally or given release

time for academic service

Athletic trainer may perform administrative

oversight, including financial, logistic, and

operational aspects of sports medicine

program

Athletic trainer and team physician employed

full time by athletic department

Allows closer relationship between

sports medicine and athletic

department personnel and between

team physician and AT

Potential conflict of interest if athletic personnel

control athlete’s medical care

Usually found in larger institutions with

greater financial resources, medical

demands

May enhance communication between

medical and athletic personnel

Athletic trainer, team physician may be

challenged by athletic personnel over

inappropriate return to play, medical

clearance, other medical decisions

Athletic trainer may provide administrative

oversight, including financial, logistic, and

operational aspects of sports medicine

program

Clarifies team physician’s responsibility

Athletic trainer employed by educational

program

Reduces or minimizes conflict of interest

in making medical decisions based

solely upon athlete’s medical needs

Athletic personnel may perceive lack of

commitment, increasing communication

challenges between medical and athletic

personnel

More common in secondary schools than

collegiate settings

May provide AT professional

advancement opportunities through

academic promotions, longevity,

enhanced credentials

Athletic trainer may experience role conflict,

sacrifice athlete’s medical care for

educational demands, responsibilities

Team physician usually employed externally;

serves voluntarily or is contracted for

service to institution or school (athletics

only or institution as a whole), either

through retainer or fee for service; or team

physician may be employed by

educational program

Reduced conflict between classroom-

taught clinical practices and those

carried out in clinical setting, thereby

improving consistency, instruction

clarity for students

Athletic trainer typically has primary

responsibilities in academics as instructor

or preceptor and defined role in athletics;

split responsibilities may be part of regular

contract or AT may be employed by

academics and compensated additionally

or given release time for athletic service

Increased expectation and monitoring of

continuing education by educational

department may encourage AT to

stay current on evidence-based

clinical practices, improving athletes’

quality of care

Athletic trainer or team physician (or both)

employed by university health center or

school health services

Minimizes conflict of interest in making

medical decisions based solely upon

athlete’s medical needs

Athletic department may perceive lack of

commitment toward its personnel, increasing

communication challenges with medical staff

University health center provides all health

care services to students, including

athletes

Athletic trainer afforded all rights,

privileges of medical provider

Athletic department does not control athletes’

health care or ATs’ employment

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overrule the treating physician if he or she agrees with the

athletic trainer that it is necessary to restrict the athlete’s

participation status.

We recommend that



Athletic trainers work under the direction of a team

physician based on their state practice act and professional

standards;



Athletic trainers follow policies and procedures that are

written in conjunction with the team physician and

supported by the school adm inistration;



Athletic trainers communicate return-to-play concerns with

the team physician, with whom the ﬁnal authority rests;



All athletes undergo a comprehensive preparticipation

physical examin ation and no athlete be allowed to practice

or compete until documentation of the examination is

provided;



All schools with athletic programs have emergency action

plans that are written, posted, and practiced by all who have

responsibility for the acute management of athletes’ injuries

and illnesses;



All schools have an appointed or designated team physician;

and



All schools with athletic programs provide an adequate

number of sports medicine providers, speciﬁcally and most

appropriately athletic trainers, based on the number of

athletic tea ms and athletes.

Policy and Procedure Recommendations Regarding

Administrative Authority for the Selection, Renewal,

and Dismissal of Athletic Trainers in the College and

University Settings

The sports medicine staff should have ﬁnal, unchallenge-

able authority for the health and welfare of the athletes. The

athletic trainer should be appointed as a senior athletic

administrator to provide for the health, safety, and welfare

of all athletes and have input into administrative areas such

as the budget, risk management, institutional liability,

quality assurance, and athlete satisfaction. This organiza-

tional structure sends a clear message that the athletic

director recognizes the value of and has esteem for athlete

welfare. As a senior administrative appointment, the

athletic director should not cede authority over sports

medicine or sports medicine providers to a coach. The

institution and all applicable employees should be aware of

and adhere to all state regulations regarding the creden-

tialing of all sports medicine providers.

The athletic trainer should be directed and supervised

with regard to administrative tasks by the athletic director,

with regard to medical competence by the team physician,

and with regard to academic competence by the academic

department chair or dean. A coach should never be the

direct supervisor of an athletic trainer due to conﬂict-of-

interest concerns. All institutional employment protocols

and procedures for selection, evaluation, renewal, and

Table 1. Continued.

Advantages Disadvantages

Requires a well–thought-out communication

plan so that relationship is seamless and

timely information is provided to athletic

personnel

Salaries typically comparable with those

of other medical professionals

Athletic department does not receive insurance

reimbursements for sports medicine services

Administrative tasks usually assigned to

staff members, freeing AT for clinical

care and allowing better work–life

balance

Health service staff must understand athletic

program intricacies and demands; in-service

education may be necessary

Staff with most expertise supervises

medical services, billing,

reimbursement, etc

Student health services may not employ the

most expert sports medicine specialists in

area

Medical records, referrals, related

services managed in 1 place without

duplication, division of efforts

Comprehensive care for student–athlete

facilitated as both participation-related

and other health care delivered

through health service

Medical care contracted with outside hospital

or private group

Significantly reduces athletic

department’s responsibility for and

control over medical decisions and

promotes unity among medical team

Due to lack of medical expertise, institution

may be challenged in evaluating competitive

bids for best medical care provider versus

best financial package

Institution contracts to separate entity

(usually hospital) for all medical services;

contracts may be awarded based upon

bids

Can streamline continuity of care among

medical providers

Some outside groups may lack appropriate

personnel for every medical situation or

specialty needs

Communication challenges between athletic

and medical personnel may be greater

May be difficult to determine, reconcile

appropriate needs for equipment,

expendable supplies, staffing

Abbreviation: AT indicates athletic trainer.

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dismissal should be followed. A clear, complete outline of

the speciﬁc job expectations should be provided and

understood before the employment agreement is ﬁnalized.

When an athletic trainer has responsibilities to more than 1

department, a clear delineation of reporting lines, percent-

age of duty expectations, and performance-appraisal

weighting should be established.

Policy and Procedure Recommendations Regarding

Administrative Authority for the Selection, Renewal,

and Dismissal of Athletic Trainers in the Secondary

School Setting

Selection of an Athletic Trainer. If a head athletic

trainer is on staff, this individual should have signiﬁcant

responsibility in the hiring process within the school’s

policies and procedures. This includes developing the

position vacancy notice, reviewing applications, checking

references, and conﬁrming appropr iate credentials and

licenses of the candidates, as well as selecting the top

applicants to begin the interview process. In the absence of

a head athletic trainer, the athletic director and principal

should be responsible for the hiring process, as well as the

school’s human resources department, if applicable.

All aspects of the athletic trainer position should be

addressed in the interview.

These include but are not

limited to supervision, direction, evaluation, authority,

budget, policies, protocols, and applicable district, state,

and national laws, rules, analysis of liabili ty, and

malpractice coverage. It should be noted during the

interview that unquestionable ﬁnal authority for rendering

medical decisions should rest with the team physician or his

or her designee, who could be the athletic trainer.

Retention of an Athletic Trainer. Renewal of the

athletic trainer’s employment should be based on a

comprehensi ve, fair, and equitable e valuation process

involving all aspects of the job performance and duties.

The evaluation process should be performed by the team

physician, athletic director, and principal, each evaluating

competence in their areas of responsibility as outlined in

Table 2.

The team physician should evaluate athletic training

services, and review of all nonmedical duties associated

with functioning as an athletic trainer should be completed

by the team physician, the athletic director, or principal or

designee (or a combination of these). In some areas of the

review, the athletic director and team physician may ask for

a coach’s input. The coach’s comments should not be the

only ones considered in the review process but can serve as

a starting point for communication and dialogue. This way,

personality conﬂicts and lack of understanding of the

athletic trainer’s responsibilities will not affect the review

process. Just as the coach would not want the athletic

trainer to evaluate his or her ability to coach or select

starting line-ups or plays, the athletic trainer does not want

the coach to assess how he or she evaluates, manages, and

treats an athlete’s knee injury. Situations in which the

athletic director is also a coach may present a potential

conﬂict of interest. In these cases, the performance review

of the athletic trainer should be the responsibility of the

team physician and a suitable alternate or designee (eg,

assistant athletic director or principal).

Dismissal of an Athletic Trainer. The periodic perform-

ance-appraisal process holds employees accountable for

competent performance in the following areas



Technical standards, derived from the job description;



Behavioral standards, derived from the district handbook;



Mandatory standards, applicable to all individuals;



Goals and objectives, as mutually agreed upon at the

beginning of service; and



Competencies, developed in accordance with the individu-

al’s job and in compliance with governing agencies that set

required standards.

In addition, the periodic performance-appraisal process

should include the following



Needs assessment for future educational programming;



Career development for future career aspirations;



Physical-demands checklist to determine the physical

requirements of each job;



Educational record;



Personal note section for documenting accomplishments ;

and



Performance log for documenting corrective action in a

speciﬁed time period.

An employee may appeal the review or dismissal

decision to the appropriate school or medical administration

within a speciﬁed time period if his or her overall

performance appraisal score or any individual score is

viewed as unsatisfactory.

Table 2. Assessing the Athletic Trainer’s Employment in the Secondary School Setting

Personnel Involved

Team Physician Athletic Director Principal

Athletic trainer’s

abilities assessed

Athletic training services

Education Customer service

Education Administrative duties Communication skills

Customer service Budgeting and finance

Attendance and punctuality

Communication skills Equipment Professional conduct

Quality of work Parent or guardian and coaching education

Job knowledge Customer services

Professional conduct Communication skills

Attendance and punctuality

Professional conduct

School nurse may be involved, depending on his or her level of interaction with the athletic program.

School’s business manager provides input.

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Performance-Appraisal Tools for Athletic Trainers in

the Secondary School and College and University

Settings

Performance Appraisal. Performance appraisals for

athletic trainers in the athletic setting are an important

assessment component for establishing an effective quality-

improvement program for the sports medicine team. The

goal of this section is to provide a framework and resources

that enable an administrator to effectively and efﬁciently

evaluate the performance of sports medicine staff in a

manner that enhances the selection, evaluation, retention,

and support required to facilitate a successful sports

medicine program that protects the athletes’ well-being.

These program-speciﬁc tools should be in addition to the

institution’s or school’s normal human resources policies

and practices.

The performance-appraisal tools should be based on

established goals and job objectives for each athletic trainer

and serve as a 2-way document providing an open, ongoing,

active review process throughout the year. The appraisals

should be goal oriented, focusing not just on past

performance but also on future improvement and profes-

sional development. Performance appraisals should include

2 main areas: individual staff performance and athletic

training services metrics.

Program Evaluation. Institutions and schools should

have clearly written organizational charts that outline

health care services reporting and supervision plans. All

members of the sports medicine team should have clear,

written job descriptions that serve as a platform for

developing yearly goals and benchmarks and describing

day-to-day job duties. These should be developed and

reviewed at the beginning of the year so that staff can plan

for and perform their jobs effectively. Supervisors should

provide timely feedback and periodic review throughout the

year, avoiding the 1-time, end-of-the-year assessment. This

written and planned process allows for open and transparent

communication between staff and supervisors. Written

goals and benchmarks provide an objective basis for job

success and movement toward promotion. Written job

objectives can help demonstrate day-to-day workloads and

priorities to athletic administrators and human resources

departments.

Individual Staff Performance. Individual staff

performance is best evaluated using tools available for

both announced and unannounced evaluations. These tools

should be designed for the speciﬁc setting (eg, athletic,

clinic, health center, hospital, academic) so that athletic

directors as well as health care administrators feel

comfortable conducting the evaluation and interpreting

the results.

The performance process should include not only tools

but also a description of the process and the roles of all of

the team members: team physician, athletic director,

coaches, athletes, faculty, and peer athletic trainers.

Institutions and schools should distinguish between the

roles of the athletic director and the team physician in the

evaluation process. There should be options for allowing

athletes the opportunity to provide feedback, such as

through an athlete committee, a standard survey, a per-visit

feedback form, or an exit interview. The goal is to allow

coaches and athletes to provide valuable feedback in a

manner that can lead to improvements in care and service.

Staff members should be encouraged to provide self-

assessments of their performance toward accomplishing their

set goals and job objectives. This helps with the 2-way

communication model described above, as perceptions and

expectations may differ between employees and supervisors.

A supervisor should be encouraged to have 1-on-1

meetings with each employee to discuss goals, accomplish-

ments, continuing education, and areas for improvement.

As noted throughout this section, the review process should

be goal oriented and should take place throughout the year,

rather than only at the end.

Teaching. An important component to some sports

medicine programs is the education and clinical

supervision of young professionals in accredited

programs, in the secondary school setting, or teaching-

related classes. Staff workloads should account for teaching

and clinical education responsibilities as well as medical

care responsibilities. Many sports medicine staff members

have a faculty teaching, adjunct instructor, or clinical

instructor role that should be accounted for in the initial

goal-setting stage and in individual job objectives at the

beginning of the year and be tied directly to the instructor

evaluations. These academic or clinical evaluations should

be used as part of the staff member’s overall performance

appraisal and addressed within the promotion a nd

remediation planning and workload modiﬁcations.

Promotion and Remediation Plans. Formal per-

formance appraisals can be used in discussions on raises,

promotions, and workload modiﬁcations. Performance

appraisals should include a formal remediation plan with

an established, individual timeline for each sports medicine

team member to seek professional development

opportunities and correct unsatisfactory actions.

Athletic Training Service Metrics. It is important to

evaluate the overall sports medicine program in addition to

individ ual staff performance. Outcomes from tracking

speciﬁc metrics for the medical care of athletes provided

in the sports medicine setting can supply data for

administrators to assess whether the program works and

can identify adjustments that may improve the service. The

results are often used to support resource allocation and

other policy decisions to improve service delivery and

program effectiveness. Tracking metrics can be as simple

as tallying the number of facility visits, injury evaluations,

treatments performed, or insurance claims processed each

year. An example of a more complex program-evaluation

tool is the ‘‘ Recommendations and Guidelines for

Appropriate Medical Coverage for Intercollegiate

Athletics.’’

An alternative service model tool that can

help demonstrate the value and performance of a sports

medicine program is the new College–University Value

Model and forthcoming Secondary School Value Model.

Self-assessment tools can be used to determine whether

staff are following best practices and program policies and

assess the adequacy of the health care facility. A walk-

through checklist for facilities and programs can be used to

evaluate and serve as a guide. Athletic trainers transitioning

into a new job or job setting can beneﬁt from this type of

checklist to search for gaps in the program that should be

addressed. The ‘‘ BOC Facility Principles’’ checklist

or an

emergency plan checklist for all athletic staff are 2 good

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examples of evaluation tools that measure program

compliance and identify are as for improvement . The

‘‘ Secondary School Student Athletes Bill of Rights’’

also

lists key components of a safe and effective athletic

program.

Any gaps or expansions in service should follow a formal

remediation plan for correcting the problems or realigning

to the mission. These redirections in the program should

involve a plan, timeline, and process for accomplishing the

new goals.

Repository for Forms

In support of these aspects of sports medicine manage-

ment, the NATA has created a repository of template forms

(http://www.nata.org/sports-medicine-management), so that

athletic trainers entering a new setting will not have to start

from scratch. This repository is expected to grow and

provide additional resources, which will promote consis-

tency in evaluating athletic trainers across schools and

institutions.

DISCLAIMER

The NATA and the Inter-Association Workgroup advise

individuals, schools, athletic training facilities, and institutions

to carefully and independently consider the recommendations.

The information contained in the document is neither exhaustive

nor exclusive to all circumstances or individuals. Variables such

as institutional human resource guidelines, state or federal

statutes, rules, or regulations, as well as regional environmental

conditions, may impact the relevance and implementation of these

recommendations. The NATA and the Inter-Association Work-

group advise their members and others to carefully and

independently consider each of the recommendations (including

the applicability of same to any particular circumstance or

individual). The foregoing statement should not be relied upon as

an independent basis for care but rather as a resource available to

NATA members or others. Moreover, no opinion is expressed

herein regarding the quality of care that adheres to or differs from

any of NATA’s other statements. The NATA and the Inter-

Association Workgroup reserve the right to rescind or modify

their statements at any time.

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Address correspondence to Ron Courson, ATC, PT, NREMT-I, CSCS (Co-Chair), University of Georgia Athletic Association, PO Box

1472, Athens, GA 30603-1472, [email protected], or Michael Goldenberg, MS, ATC (Co-Chair), The Lawrenceville School,

2500 Main Street, Lawrenceville, NJ 08648, [email protected].

Appendix. 10 Principles to Guide Administration of Sports Medicine-Athletic Training Services

1. The physical and psychosocial welfare of the individual athlete must always be the highest priority of the athletic trainer and the team

physician.

2. Any program that delivers athletic training services, including outreach services provided to secondary schools or other athletic organizations,

must always have a designated medical director.

3. Sports medicine physicians and athletic trainers must always practice in a manner that integrates the best current research evidence within

the preferences and values of each athlete.

4. The clinical responsibilities of an athletic trainer must always be performed in a manner that is consistent with the written or verbal

instructions of a physician or standing orders and clinical management protocols that have been approved by a program’s designated

medical director.

5. Decisions that affect the current or future health status of an athlete who has an injury or illness must only be made by a properly

credentialed health professional (eg, a physician or an athletic trainer who has a physician’s authorization to make the decision).

6. In every case that a physician has granted an athletic trainer the discretion to make decisions relating to an individual athlete’s injury

management or sports participation status, all aspects of the care process and changes in the athlete’s disposition must be thoroughly

documented.

7. To minimize the potential for occurrence of a catastrophic event or development of a disabling condition, coaches must not be allowed to

impose demands that are inconsistent with guidelines and recommendations established by sports medicine and athletic training professional

organizations.

8. An inherent conflict of interest exists when an athletic trainer’s role delineation and employment status are primarily determined by coaches

or athletic program administrators, which should be avoided through a formal administrative role for a physician who provides medical

direction.

9. An athletic trainer’s professional qualifications and performance evaluations must not be primarily judged by administrative personnel who

lack health care expertise, particularly in the context of hiring, promotion, and termination decisions.

10. Universities, colleges, and secondary schools should adopt an administrative structure for delivery of integrated sports medicine and athletic

training services to minimize the potential for any conflicts of interest that could adversely affect the health and well-being of athletes.

Used with permission from Human Kinetics.

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